What is Evidence-Based Practice?

In this module, we will begin to learn about evidence-based practice, why it is important in what we do as nurses, and the purpose of evidence-based practice in nursing.

Content includes:

• The Need for EBP
• Alternative Sources for Evidence
• EBP in Nursing
• Brief Overview of Quality Improvement and Research Utilization
• Conceptual Frameworks

Objectives:

1. Explain why evidence-based practice is needed in nursing
2. Describe alternative sources of “Why we do what we do” [anecdotal evidence]
3. Describe “evidence-based practice” in nursing
4. Explain the purposes of evidence-based practice in nursing
5. Describe conceptual frameworks
6. Differentiate quality improvement and research utilization

Introduction to Evidence-Based Practice

First, let’s review the definition of evidence-based practice (EBP): The act of basing practice on best evidence to make patient care decisions to improve outcomes and being cost effective.

EBP is a broad concept referring to the incorporation of current, valid, and relevant external evidence during the decision-making process. In the health sciences, such evidence is most commonly found in current high-quality research studies that can be applied to the specific patient, group, or population being considered.

Alright, now that we have a basic description of evidence-based practice (EBP) and know what it is, let’s talk about why it is such a big deal in nursing and then work on understanding more about it and then work on applying it to your current clinical practice as a nursing student.

EBP in nursing has at its core concept, improving health care outcomes. In addition to improving outcomes, it is also concerned about keeping costs down.

Let’s think about this for a second. Let’s say we discover an awesome new pharmaceutical that eliminates insulin-resistant diabetes, but that same medication costs $29,990.00 per weekly dose and it must be taken for life. Would this be cost effective? It seems not, but perhaps it is more cost effective than all the ramifications that come from diabetes. This is considered when we look at efficacy of a new treatment. So, while we could improve health care outcomes with this new medication, it may or may not be cost effective to do so.

Changes in nursing care are happening every day. New studies are being conducted that change the best evidence available in some cases. So, to further the point of why EBP is important in nursing, let’s think about why we do what we do in patient care. How many times have you read one method to perform a skill in a textbook, but yet an instructor tells you something different, and then you might even see it done a different way in clinical. Why is that? Well, there are a few reasons for that and we will explore those in a bit. Let’s look at another scenario, first.

In the early 1900’s, it was thought that flowers should never be placed in a hospital room because they would consume much-needed oxygen and rob it from the patient. In fact, during a recent orientation at a hospital on the evening shift, the nurse preceptor explained to the orienting nurse that every evening at 9 pm, all flowers and plants are removed from the patient rooms and stored until the following day. The nurse preceptor explained that “this is the way we have always done it here.” This act was based on fallacies and inaccurate science. In fact, this error in thinking traces back to 1923 in print form and spread by word of mouth from there. In a study published in International Archives of Occupation and Environmental Health (1977), the author reported that plants altered oxygen and CO2 levels by about 1.5% – a very negligible amount (Gale, Redner-Carmi, & Gale, 1977). When you consider that a human being, such as the person in the bed in the hospital room, uses up about 2.5 cubic feet (71 liters) of oxygen in an hour, while a pound of foliage sucks up about 0.026 gallons (0.1 liters) in that same time period, it would make far more sense to ban oxygen-sucking visitors than to ban flowers! Additionally, Park and Mattson (2009) studying therapeutic influences of plants in hospital rooms, reported that, “Patients in hospital rooms with plants and flowers had significantly shorter hospitalizations, fewer intakes of analgesics, lower ratings of pain, anxiety, and fatigue, and more positive feelings and higher satisfaction about their rooms when compared with patients in the control group.” It seems that patients benefit from having flowers in their rooms.

Some students get to this point and wonder, “But, why do we need to know this in a nursing program? We aren’t nurses yet!”

Well, let’s dive into that briefly. As a nursing program, we adhere to the standards by the American Association of Colleges of Nursing (AACN). AACN has specific essentials that various levels of competencies that nursing students should meet by the time they graduate. If you would like to take a look at these, navigate to this website: https://www.aacnnursing.org/Essentials

Here are the competencies that AACN clearly outlines to the entry-level nursing student (that’s us!) to achieve as they relate specifically to evidence and EBP:

1. Evaluate clinical practice to generate questions to improve nursing care.
2. Evaluate appropriateness and strength of the evidence.
3. Use best evidence in practice.
4. Participate in the implementation of a practice change to improve nursing care.
5. Participate in the evaluation of outcomes and their implications for practice.
6. Explain the rationale for ethical research guidelines, including Institutional Review Board (IRB) guidelines.
7. Demonstrate ethical behaviors in scholarly projects including quality improvement and EBP initiatives.
8. Advocate for the protection of participants in the conduct of scholarly initiatives.
9. Recognize the impact of equity issues in research.

Stated by the AACN:

“Knowledge of the basic principles of the research process, including the ability to critique research and determine its applicability to nursing’s body of knowledge, is critical. Ethical comportment in the conduct and dissemination of research and advocacy for human subjects are essential components of nursing’s role in the process of improving health and health care. Whereas the research process is the generation of new knowledge, evidence-based practice (EBP) is the process for the application, translation, and implementation of best evidence into clinical decision-making. While evidence may emerge from research, EBP extends beyond just data to include patient preferences and values as well as clinical expertise. Nurses, as innovators and leaders within the interprofessional team, use the uniqueness of nursing in nurse-patient relationships to provide optimal care and address health inequities, structural racism, and systemic inequity” (AACN, 2021).

If you proceed on to a graduate-level program, these competencies level up a bit to a higher standard. The Essentials are a direct analogy of “Why we do what we do” at the nursing department curriculum development level. They also guide our development of courses. This EBP course is not a course grabbed out of thin air just to subject some maddening frustration upon you. BSN programs nationwide have some type of EBP course just like this one. Some have their students develop scholarly, evidence-based papers and some have their students develop EBP projects or posters like this course. They all have the same goal: To create a better understanding of how to read published evidence, how to utilize that evidence in practice, and how to improve patient outcomes with the best available evidence.

Undergraduate nursing students are also charged with gaining a higher level of critical thinking. This means making fewer assumptions based on hidden fallacies and also examining the status quo. Critical thinking is a purposeful, self-regulatory judgment that interprets analysis, evidence, and methodology when seeking a decision. Critical thinking means the provider should consistently evaluate how much to trust the findings of a given research study. It is a thinking skill consisting of the evaluation of arguments. In the United States and in other countries, research plays an important role in nurses’ credentialing and status. In particular, research and efforts to promote evidence-based practice are key elements of the Magnet recognition program. Changes to nursing practice now occur regularly because of EBP efforts, and these efforts enhance the status of the profession.

An emerging trend in health care research is a focus on patient-centeredness and the degree to which evidence applies to individual patients, small groups of patients, and local contexts. Attending to the applicability of research findings is likely to become an increasingly important goal for nurses pursuing an evidence-based practice.

Before we can really understand some of the alternative sources of “what we do”, let’s look at the timeline of conducting a research study and how long it may take to get the results of that study into practice. There is a standard refrain of “17 years to move evidence into practice” and indeed there is a long gap that prevents amazing research from being embedded (if ever) into clinical practice (IOM, 2001).

Timeline of evidence into clinical practice:

• Testable idea must be formulated and refined.
• Research team must be assembled.
• Preliminary data gathered.
• Permissions must be obtained.
• Regulatory requirements must be met.
• Support must be obtained, including personnel, supplies, and funding.
• Subjects must be enrolled.
• Interventions must be delivered.
• Data must be collected.
• Analyses performed.
• Dissemination (sharing) of data through presentations and publications.
• Then, and maybe then, practitioners and/or facilities investigate embedding this into practice.
• Assessment must be completed to see if these changes are working/not working.
• And so on.

Moving research into practice is a delicate balance of incorporating new findings quickly enough to maximally benefit patients, but not so quickly that we expose patients to unnecessary harm (Munro & Savel, 2016).

We now see that there can be a very long process to embed latest/most current, best evidence into practice. In the meantime, this lack of embedding best evidence in clinical practice may be harming the efforts to improve clinical outcomes. If clinicians are just doing “what we’ve always done”, and we are not using the best evidence that is out there, this creates an issue.

Some sources of evidence for our current clinical practice may be:

• Tradition and authority/ “experts”
  • Change is difficult. Many nursing decisions are based on history. We just do what we’ve always done. No one has rocked the boat. Things seem alright, why change?
  • Anecdotally, things sometimes just “work”. However, sometimes our actions are based on false assumptions, untrue facts, and unreliable personal accounts. How much of what we do is based on anecdotal evidence? Think about this a bit. Think of every skill you’ve learned in nursing school so far. Is there evidence to support it? Or, are you simply doing what someone has taught you and you have relied on their authority and expertise? How do you know if it is the best method that is rooted in scientific evidence?
  • There is what is considered a “unit culture”. Many decisions are made based on tradition or the guidance of an authority. These types of knowledge are so much a part of a common heritage that few people challenge their efficacy or seek verification. Such “sacred cows” are widely used to guide practice, but they are a weaker form of knowledge than disciplined research.
  • Standards persist. Here’s an example: It is no longer best evidence to perform an air bolus with an auscultation test to ensure placement of a nasogastric tube. Best evidence supports obtaining a pH and then a chest radiograph to confirm placement (AACN, 2016). We discovered this about 12 years ago! Yet, there are still textbooks, clinicians, instructors, manuals, websites, and institutional policies that support the air bolus method of placement confirmation. A 2015 study showed that more than 88% of nurses were currently using nonevidence-based practices to verify NGT placement, creating a serious patient safety issue (Relias Media, 2015).
  • It is often difficult to challenge an expert. Reliance on experts and mentors is unavoidable and their information is often unchallenged.
  • Lastly, it takes time to look up best evidence. The easy way out is to just do what we’ve always done. Yikes! Did you know that it used to be standard to use heat lamps to dry up wounds? Someone somewhere finally asked, “Is this really the best way to treat wounds?” and now we have evidence from research that points us to moist dressings. Heat lamps? Really? Yes – we did that. Oh my, how far we have come. But, we have to keep looking at the latest evidence. Who knows… maybe future research will tell us that dressings of bananas and chia seeds is best for wounds. Doubtful, but one never knows! We have to continually keep seeking more evidence with everything we do.
• Clinical experience
  • This is a functional source of knowledge, right? Experience (expertise) is even a component of the EBP triad (we will learn that in a bit). However, it has limitations because every nurse’s experience is different than the next nurse. This makes the overall pool of experience a bit narrow and often somewhat biased as each individual comes to the proverbial table with a different outlook, experience, opinion, or background.
• Disciplined research: Disciplined, systematic research. Now, this is considered the gold standard of what we should be basing our clinical practice on. However, we can’t forget that nursing is not just “science” but a blend of our personality, caring, and art.

The integration of research findings into healthcare settings has been happening on some level for hundreds of years (Hall & Roussel, 2014). Practitioners and even lay persons took what they learned in their application of some medicinal properties, shared this information, and implemented it into a broader population. However, the research was limited and often not based on sound science and often not shared past a smaller community.

In recent years, starting in the late 20th century, evidence-based practice became a concentrated focus in nursing. Nursing now has developed various models, including the triad of EBP, to help guide EBP into practice.

Evidence-based practice in nursing is based on three principles, or the triad of EBP. At the core of the triad is improved patient/clinical outcomes.

These principles of the Triad of EBP include:

• Patient preferences or values
  • This means, if the patient’s own situation renders the intervention not appropriate for them, or if their own social or cultural values do not align with the intervention, then the process stops there.
• Clinician expertise
  • Decision making also includes the individual clinician’s expertise, which includes academic knowledge, experiences with patient care, and interdisciplinary sharing of new knowledge (Polit & Beck, 2021). Even very strong evidence is seldom appropriate for all patients, so clinician expertise is important.
• Best available current clinical evidence
  • The basis of EBP is to de-emphasize utilizing tradition, opinions, and anecdotal evidence.
  • Therefore, the best evidence is essential to EBP. We will explore how to determine which evidence is “best” in a bit. But, for now, just know that whatever evidence, whether we determine it to be “best” or not, is never enough by itself for the foundation of a clinical decision-making process.
  • Finally, a big concept of this is knowing that one research study (even if it is the best study ever) does not equal EBP. This means, we must consider multiple pieces of evidence to consider synthesizing the results. We will come back to this.

Hot Tip! If one of the principles of the EBP triad is missing, we no longer can have EBP. All three components must be present for the loop to close and for improved patient outcomes to come to fruition.

As we have learned already, EBP is the result of research. EBP itself is not research. Research, as we will learn more about, is a systematic investigation about a perplexing problem or something we desire to find more about. Research produces evidence, and then we take the best of that evidence and apply it to clinical settings – and that is EBP.

As we dive further into this course, we will be learning how to locate evidence that helps to guide our nursing actions. For the most part, nurses utilize databases that house peer-reviewed, scholarly articles that are based on research projects. We can also find clinical guidelines that are based on evidence in multiple locations, including UpToDate, which is a clinical medicine database that provides coverage of over 8500 topics, Joanna Biggs Institute EBP Database (JBI), the National Guideline Clearinghouse (AHRQ), Institute of Medicine (IOM), and others.

That brings us to ask, “What are the various purposes of research in the first place?” Researchers must ask a question that they would like to explore with a study (we will come back to that in detail). Let’s explore five types of research purposes and the inquiries that are linked back to EBP.

First, the specific purposes of nursing research include identification, description, exploration, explanation, prediction, and control. Utilizing these purposes, here are the common types nursing research:

• Therapy/Intervention:
  • The purpose of these clinical questions/inquiries is directed by health care/nurse researchers to learn more about specific treatments, interventions, actions, products, or processes.
  • Example: This study examined if a smoking cessation program increased the number of patients who quit smoking.
• Diagnosis and Assessment:
  • The purpose of these questions is concerned with methods and instruments utilized to help diagnosis or screen a condition, or to assess a clinical outcome.
  • Example: Resnick and colleagues (2020) developed and rigorously evaluated the Checklist for Function-Focused Care in Service Plans, using data from 242 people living in assisted living facilities. The checklist was designed to assess whether service plans were helping to optimize physical activity and function.
• Prognosis:
  • The purpose is concerned with understanding the eventual outcomes or consequences of diseases, conditions, or health problems.
  • Example: This study investigated the rate of depression amongst individuals with limited mobility.
• Etiology (Causation [think “cause and effect”])/Prevention of Harm:
  • The purpose is all about understanding the cause or determinant of what results in a health problem; it is “cause-probing”.
  • Determining factors and exposures that lead to, cause, or affect various illnesses, mortality, or morbidity is the focus with this type of inquiry.
  • Example: This study identified factors associated with risk of fatalities amongst smokers infected with coronavirus.
• Meaning and Processes:
  • Think of the purpose here as gaining insight into perspectives of our clients. This type of study is done via qualitative methods, which we will learn about soon. There is no intervention or measurement being done, but simply a study to investigate how clients are perceiving their treatments, diagnosis, etc., to better understand how we can motivate compliance with treatment and design appealing interventions.
  • Example: This study explored the experiences and journey through their breast cancer treatments of women in the U.S.

Conceptual & Theoretical Frameworks

One tricky concept that underlines the basis for research projects and much of the “why” and “how” in a phenomenon is the term “conceptual frameworks” (or “conceptual model”). You can think of this term as a fancy phrase for “a way to explain something”. Conceptual frameworks, as a broad phrase, are the use of theories, models, or concepts to guide research, nursing research, and nursing practice. The link between theory and research is reciprocal in their relationship. Every study contains a framework as a foundation to guide the research. Think of a framework as the frame of a house before the sheetrock, doors, and windows are inserted. Without the frame, the sheetrock, doors, and windows would have no support.

Remember, nursing is a mix of science and art, and we care for people in a variety of ways. For example, Florence Nightingale, considered one of the first nurse researchers and a holistic nurse, wrote about the impact of the environment to health (Nightingale, 1860). We still use Nightingale’s theories of this health-environmental framework: providing fresh air, light, cleanliness, and controlling odor. Another nurse theorist, Dr. Jean Watson, developed the conceptual framework of the “Watson Caring Science Theory” that includes a human caring approach to patient care (Watson, 2020).

As you start to read published research articles, be on the lookout for conceptual or theoretical frameworks. Many authors list their underlying framework that guided their project. Here’s another example close to home. I used a theoretical framework in a study I conducted about the correlation between how adult learners perform in their associate degree of nursing (ADN) biological science prerequisites and how they do in pharmacology and pathophysiology in nursing school. Can anyone guess what type of framework I might have utilized? If you guessed something like, “Knowles’ Theory of Adult learning”, you are correct! This theory is based upon an educational and learning theory. Knowles’ theory is based upon six assumptions, which are the basis of the theory of andragogy (Merriam & Bierema, 2014).  Andragogy assumes educators need an understanding and respectfulness of the adult learners’ individuality. Since ADN students are all adult learners, this theoretical framework served to be a solid underpinning for the focus of my study.

Knowledge to application link

In this following article titled, A randomized controlled trial of enhancing positive aspects of caregiving in Thai dementia caregivers for dementia, they used the Kramer’s two-factor adaptation model as a framework for their study.

 

Here is a handy table that shows the difference, albeit sometimes there is a blurry line, between conceptual frameworks and theoretical frameworks.

Finally, researchers are creating new theories, test existing theories, and add to existing theories to explain the “why” behind things. Think of an infection control framework/model. What might be a study that could use this model? How about handwashing to prevent infections? Yes! That would be perfect. As we continue to learn about appraising research, we will come back to conceptual frameworks.

Quality Improvement and Research Utilization

Lastly, to round out this first module, let’s chat about research utilization and quality improvement. These are two phrases that you will hear in the clinical setting as well as within research articles that you may read.

Research utilization (RU) is the act of using published evidence in a clinical setting. The difference between this concept and EBP is that research utilization may lead to changes in practice that are based on the results of one study, whereas EBP answers a clinical question based on an in-depth literature search conducted to find all relevant current research evidence related to that problem.

Quality improvement (QI) projects have a goal of improving patient outcomes, but they don’t involve extensive literature reviews and are usually specific to just one facility in order to improve an existing problem. The purpose of QI projects may be to improve workflow processes, improve inefficiencies, reduce variations in care, and address clinical or even educational problems.

EBP, RU, and QI frequently overlap. There are subtle differences.

Table: Differences Between EBP, Research, Research Utilization, & Quality Improvement

Hot Tip! A big take-away from the table above, is that your EBP poster is not research. You are not performing a systematic investigation to produce new information. You are conducting a rapid review of evidence from others’ research and then summarizing it. We will delve into this a bit more in the next module.

Attribution & References

“Green check mark” by rawpixel licensed CC0.

“Light bulb doodle” by rawpixel licensed CC0.

“Magnifying glass” by rawpixel licensed CC0

“Orange flame” by rawpixel licensed CC0.

American Association of Critical-Care Nurses. (2016). Feeding tube placement. https://www.aacn.org/newsroom/feeding-tube-placement

American Association of Colleges of Nursing. (2021). The Essentials: Domain 4: Scholarship for the Nursing Discipline. https://www.aacnnursing.org/Essentials/Domains/Scholarship-for-the-Nursing-Discipline

Gale, R., Redner-Carmi, R. & Gale, J. (1977). Impact of the respiration of ornamental flowers on the composition of the atmosphere in hospital wards. International Archives of Occupational & Environmental Health, 40, 255–259. https://doi.org/10.1007/BF00381413

Hall, H. & Roussel, L. (2014). Evidence-based practice: An integrative approach to research, administration, and practice. Jones & Bartlett.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academies Press.

Merrian, S. B., & Bierma, L. L. (2014). Adult learning: Bridging theory and practice. Jossey-Bass.

Munro, C. & Savel, R. (2016). Narrowing the 17-year research to practice gap. American Journal of Critical Care, 25(3), 194-196.

Nightingale, F. (1860). Notes on nursing: What it is and what it is not. D. Appleton & Company. http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html

Polit, D. & Beck, C. (2021). Lippincott CoursePoint Enhanced for Polit’s Essentials of Nursing Research (10th ed.). Wolters Kluwer Health.

Pankong, O., Pothiban, L., Sucamvang, K., Khampolsiri, T. (2018). A randomized controlled trial of enhancing positive aspects of caregiving in Thai dementia caregivers for dementia. Pacific Rim Internal Journal of Nursing Res, 22(2), 131-143.

Park, S., & Mattson, R. H. (2009). Therapeutic influences of plants in hospital rooms on surgical recovery. HortScience , 44(1), 102-105. https://doi.org/10.21273/HORTSCI.44.1.102 

Relias Media. (2015). Misplaced NG tubes a major patient safety risk. Healthcare Risk Management. https://www.reliasmedia.com/articles/135136-misplaced-ng-tubes-a-major-patient-safety-risk